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Patient Screening Form

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Patient Screening Form

Use this form to screen patients before their appointment and when they arrive for their appointment.

Who Answered
Contact Method
Patient temperature in office today

Identify yourself and explain the purpose of the call, which is to determine whether there are any special considerations for their dental appointment. Have the patient answer the following questions.

Screening Questions

Have you had close contact with anyone acute respiratory illness or travelled outside of Ontario in the past 14 days?
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
Do you have any of the following symptoms:
  • Fever
  • New onset of cough
  • Worsening chronic cough
  • Shortness of breath
  • Difficulty breathing
  • Sore throat
  • Difficulty swallowing
  • Decrease or loss of sense of taste or smell
  • Chills
  • Headaches
  • Unexplained fatigue/malaise/muscle aches (myalgias)
  • Nausea/vomiting, diarrhea, abdominal pain
  • Pink eye (conjunctivitis)
  • Runny nose/nasal congestion without other known cause
Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
  • Any "yes" response must be discussed with the managing dentist immediately.
  • Tell the patient when they arrive at your office, they will be asked to:
    • Sanitize their hands.
    • Answer the questions again.
    • Possibly have their temperature taken.
    • Complete a form of acknowledging the risk of COVID-19.
  • Advise the patient:
    • Only patients are allowed to come to the office.
    • If possible, to wait in their car until their appointment, call the office when they arrive.